In the report Five Years After to Err is Human, it was noted that "the combination of complexity, professional fragmentation, and a tradition of individualism, enhanced by a well-entrenched hierarchical authority structure and diffuse accountability, forms a daunting barrier to creating the habits and beliefs of common purpose, teamwork, and individual accountability for successful interdependence that a safe culture requires." Training physicians, nurses, and other professionals to work in teams is a concept that has been promoted by many patient safety experts. This application seeks to build upon the clinician communication, teamwork, and microsystem risks identified in a currently funded study, Risk Assessments of Pediatric Emergency Transfers (1 P20 HS017125, Agency for Healthcare Research and Quality), through integration of these risks into the development, evaluation, and dissemination of an in-situ simulation training focused on the receipt of pediatric emergency transfer patients. This application will also integrate specific TeamSTEPPS(tm) skill categories to address the identified clinician communication, teamwork, and microsystem risks. By conducting the simulations in-situ-in the operational environment of health care units and floors-both microsystem as well as organizational systemic or process risks are likely to be revealed. The specific aims include: Aim 1. Develop in-situ simulation trainings to address communication, teamwork, and microsystem risks for receipt of pediatric emergency transfers;Aim 2. Conduct the risk-informed in-situ simulations;Aim 3. Conduct a risk-informed evaluation of the impact of in-situ simulation as an intervention to improve the safety for receiving pediatric emergency transfer patients through assessment of the change in communication, teamwork, safety culture, and microsystem risks;Aim 4. Disseminate the project's findings and the In-Situ Simulation Toolkit developed to assist others with implementation of in-situ simulation. PUBLIC HEALTH RELEVANCE: Based of the findings from Risk Assessments of Pediatric Emergency Transfers and using the TeamSTEPPS teamwork skill categories, this project will develop and conduct risk-informed In-situ simulations designed to address identified clinician communication, teamwork, and microsystem risks in the receipt of pediatric emergency transfers. In-situ simulations are a realistic representation of the challenges, systems, and operational environments of health care workers. Improvement in communication and teamwork function will be assessed following the in-situ simulations and additional both microsystem and organizational systemic and process risks are likely to be revealed.